Patient relationship management, moving hospitals from curing to caring
An integrated view of the patient experience is a key lever to improve healthcare delivery quality, while balancing patient needs and business efficiency.
In today’s healthcare systems, patient care pathways can involve many different components each providing a specific area of care. Poor care interfaces and process joins can lead to inefficiency and additional cost and can diminish the patient experience and result in higher diagnostic and clinical risks.
An increasing number of hospitals recognise that good practices of Patient Relationship Management (PRM) practices can both help improve effectiveness and efficiency of the healthcare process and directly respond to the needs and experience of patients across the care pathway.
Our extensive research of healthcare organisations across Europe shows that PRM does not have to be complex nor disruptive to existing processes as long as certain factors are taken into account. This report looks at how hospitals can set a strategy and create an effective change programme for PRM which delivers measurable benefits to both hospitals and patients.
The need to manage the patient experience – learning from CRM
No one doubts the increasing demands being felt by healthcare services across Europe – driven by factors such as an ageing population with longer term healthcare needs, improvements in diagnostics and new treatments. All add to the cost of care. Care pathways are becoming increasingly complicated and with multiple providers, but are still typically designed around the needs of healthcare delivery: patients are frequently asked to move between providers to fit local processes and management of clinical resources, rather than having services configured for the benefit of patients.
These silos of service provision can have significant impacts for hospitals, such as (note 1):
• Conflicting appointments, process inefficiency and increased cost of care;
• Diagnostic risk leading to reduced treatment effectiveness;
• Lack of information sharing between departments or locations;
• Clinicians not always informed of changes to treatment;
• Poorer clinical outcomes;
• Poorer patient experience;
• Increased potential for litigation.
Meanwhile, patients and their families and carers are placing increasing demands on healthcare and its providers. Where previously a minimal appointment letter sent many weeks in advance was once seen as acceptable, many of today’s hospital users are used to fast, reliable, responsive and mobile communications – such as those provided by email, SMS and social networks – and expect care service providers to be similarly responsive and agile. Additionally, in some national healthcare systems competition is increasing between providers for patient revenues, so the inability for a healthcare provider to respond to patient expectations can lead to loss of income.
PRM is the systematic and skilful planning, decisioning, delegation and control of tasks, which serves to maintain the relationship between patients, hospitals, surgeries, pharmacies, insurers, the public healthcare system and the pharmaceutical industry, with the goal of the best possible supply of [services to] the patient and the efficient use of resources at the same time supported by information and communication technology (note 3).
So, how can hospitals respond to growing healthcare demands and patient expectations, at the same time as working with increasingly constrained budgets? The answer may come from lessons learned in the commercial sector, where relationships with consumers or customers are proactively managed to the benefit of all parties. The term ‘customer relationship management’ (CRM) has been used across a number of industries to describe best practices of engagement with service recipients – for example, retailers are considering how to improve their own customer relationships, using cross-channel strategies (note 2).
Could similar thinking be applied to understanding, monitoring and managing the behaviours of patients and clinicians along the care pathway – not only to help improve the patient experience, but also to provide benefits for providers? Examples of how this might be done include:
• Sharing visibility of a clearly defined, joined-up process with carers and patients;
• Managing how information is captured and shared, so as to simplify and speed up access for clinicians;
• Sharing reminders with clinicians and patients to improve workflow and provide process prompts.
Applied to healthcare, such a relationship-driven approach is referred to as ‘patient relationship management’ or PRM. In CRM, a ‘relationship’ is managed in order to influence customer perceptions and product sales. The ‘R’ in PRM is more about enabling mutually supportive relationships between patients and healthcare providers (figure 1).
Helping to manage the patient experience inside a hospital across the care pathway – whether a more straightforward specific acute pathway or a long-term chronic condition pathway with multiple co-morbidities – means that patients and clinicians benefit from a better and easier experience, leading to improved outcomes.
PRM has the potential to improve the patient and carer experience, whilst also improving the clinician involvement and making the health processes more effective and efficient. So how can healthcare organisations and patients benefit?
75% of healthcare organisations that participated intend to deliver patient relationship management improvement
The clear opportunity for patient relationship management in Europe
To understand how PRM practices might be applied to European hospitals, we surveyed 70 healthcare organisations including public and private hospitals, cancer centres and other providers to understand their current positions and how they could benefit from a more patient-focused approach. Based on feedback from a structured questionnaire, we were able to identify best practices and assess organisations’ levels of PRM maturity.
The top-line results of the study show that European healthcare organisations believe PRM is strategically important. Indeed, 75% of the healthcare organisations that participated intend to deliver patient relationship management improvement actions. The reasons given were not only because of benefits to hospitals (such as planning efficiency, cost savings, waiting-time management and reduced risk) but also because of rising expectations on the part of patients.
Our research focused specifically on outpatient services delivered from within hospitals – that is, patients attending hospital appointments for day treatment. Outpatient services make up a key area from a PRM perspective, as they bring together a number of strands from diagnosis through to treatment (potentially multidisciplinary treatment). As such, outpatient healthcare staff rely on information made available from across the care pathway.
A typical outpatients process is shown in figure 2. Note that services vary by country and provider, and some public healthcare providers may not have billing services.
Our research clearly demonstrates the scale of the PRM opportunity. Many of the organisations we spoke to compared the outpatients care pathway to an obstacle course. Much activity focuses on face-to-face contact and telephone reception, which can remain inefficiently managed. Here are some examples:
Appointments are mainly scheduled by phone (figure 3). The largely manual approach means that receptionists are frequently overloaded by calls.
If the same person is dealing with both scheduling and reception (as is often the case), this makes it difficult to manage other activities in parallel – such as welcoming patients, dealing with paperwork or writing up medical reports.
While some organisations are using patient-oriented thinking to support patients and carers – via the internet, SMS and social media – examples are isolated and do not demonstrate the integration of PRM across the multi-provider care pathway.
In the UK NHS a centralised electronic booking service is provided (NHS Choose and Book), which is accessible after referral by a GP. Over ten years of development the volume of transactions has increased, but the service is still not fully available nationally.
In almost half of the healthcare organisations surveyed, patients have to go to an administration desk where patient records are collated, before accessing the outpatient service (see figures 4 & 5).
For many organisations, the need to collate patient records is a significant cause of waiting time. For administrative staff, it is not easy to anticipate the time required to complete registration documents, resulting in inefficiency and delay.
We found that the resulting delays cause stress to patients on the day of their appointment. Administrative staff have then to manage discontented patients who want to go as quickly as possible to the outpatient service.
Following an appointment, patients may need to schedule further appointments. From a patient’s perspective, it is easiest to organise the next steps just after a consultation.
If another appointment is needed in the same specialty, a medical secretary can organise the appointment directly.
If the appointment has to take place in another department, it can be the responsibility of the patient to organise the next steps of the pathway. This may not be straightforward, particularly given that it is not usually possible to book appointments outside working hours, and is usually timeconsuming (figure 6).
Clearly the task of scheduling patients and clinicians together with appropriate appointments is complex. Even when the process works and patients successfully arrive at appointments, a significant consequence of inefficiencies in the process is ‘waiting’. Patients entering a hospital can face several waiting lines: at the administrative desk, at the outpatient service, for diagnostic services and to arrange follow-up appointments. Waiting times undermine the patient’s experience and can even lead to reduced treatment effectiveness. As John Czepiel explains in his book The Service Encounter (note 4), a number of psychological principles apply:
• Anxiety makes waiting seem longer;
• Waits of uncertain length are harder to tolerate;
• Waiting feels longer when you don’t know the reason for the wait;.
• Pre-process waits feel much longer than inprocess waits;
• Occupied time feels shorter than unoccupied time.
Responding to the challenges with PRM
Given that healthcare organisations know (at least, at a strategic level) what PRM can achieve and given the compelling nature of the research, what steps can be taken to improve PRM practices within hospitals? From both our research and experience learned from our clients we can draw out a number of good practices. A central premise is that PRM implementation should not require ‘boiling the ocean’; low-cost, straightforward actions are possible at every stage.
Identify local problem points in the process through listening to stakeholder feedback – patients, staff, clinicians and partners
Clearly, patients and their families are the most important stakeholders in the care process. Successful PRM implementations emphasise continual feedback from patients, families and carers, whilst ensuring that the starting point for improvement measures is the relationship between the hospital, patients and their families.
PRM implementations should focus on straightforward actions at every stage
Based on our study, we recommend reviewing contact processes from a patient perspective – for example, through use of simple listening and feedback tools, to understand where patients are experiencing issues and to gain insight into how they can be improved.
Equally, staff, clinicians and partner organisations can be involved in improving contact and engagement processes to deliver an excellent patient experience. By involving all stakeholder groups, PRM deployments can encourage greater engagement and adoption from clinicians.
Consider alternatives to ‘patient comes to hospital’ delivery models
Not all patient interactions are best handled within the hospital and by the processes that (by necessity) they have to use to manage demand on their resources. Whilst the hospital is often seen as the ‘first port of call’ for all medical emergencies or non-emergencies, the patient (and staff) can get frustrated when the setting is inappropriate to the care. For example, better triage of patient problems before they come to hospital may mean that they can be directed to more appropriate services provided outside of the hospital or even by telephone, thereby improving the patient experience and alleviating demand on hospital-based emergency services.
The UK’s NHS Direct service is an example of a project aimed at reducing the use of emergency departments at hospitals for non-urgent care. The system was set up in 1998 to provide advice and health information by telephone and online on a 24-hour/7-day basis, as well as supporting patients suffering from chronic diseases, and providing access to out-of-hours GP and dental care.
A more recent UK initiative is the provision of a national, non-urgent telephone health service (through a 111 number, rather than the emergency 999 number in the UK). This is still in the early stages of deployment.
Finland has also implemented healthcare access without appointments. Basic nursing services are offered by way of ‘health kiosks’ located in shopping malls, which provide ‘drop-in’ consultations. These services are available without appointment and are free of charge.
Our recommendation is to consider all possible options to enable patients to find information, to engage with hospitals and to deal with their own needs. Again, these do not have to be complex – better signposting, online and helpline services can play a role, as can external clinics, drop-in centres and mobile applications.
million appointments were missed in the NHS in 2011–12, costing EUR 117 each time
Review information and communications technology systems (ICT)
ICT has typically evolved to support the healthcare transaction, by recording facts. ICT can also bring together and share information to support the engagement and relationship between staff and patients. While this can exploit existing enterprise technology, you should also take the opportunity to see where new, potentially low-cost add-on technologies can support the patient journey.
Many organisations face the challenge of using older technology that is still in working order. For example, in our research we found that the majority of organisations we surveyed still rely on older switchboards and call-management systems: only 23% use an interactive voice response to sort incoming calls (figure 7), and only 26% of switchboards can tell patients about how busy the organisation is at any given moment or the estimated waiting time in the telephone queue.
The use of technology can be highly cost-effective. For example, 5.5 million appointments were missed in the NHS during 2011–12, at an average cost of EUR 117 each time. Manual phone reminders cost about EUR 0.90 per patient and reduce nonattendance by 39%; meanwhile automated phone or SMS reminders reduce non-attendance by 29%, at a cost of only EUR 0.14 per patient.
Social networks also offer an opportunity to improve communication between staff and patients – for example, to provide up-to-date information on hospital access (‘The North Car Park is closed this week due to maintenance’) or for patients to gain quick access to transactional information (‘Could you confirm the opening time?’).
Another benefit of social media technologies is to enable patients to share their experiences (both positive and negative) of dealing with health service providers. In many cases these anecdotes and reviews are helpful to other service users as they plan visits to hospitals; the feedback is also valuable as part of the ‘hospital listening’ feedback loop. Our research found that only 16% of the healthcare organisations we surveyed are present on social networks.
The majority of staff welcomed local innovation as an opportunity to drive improvements. Our recommendation is to pilot specific technologies and approaches in an iterative, but structured manner – led by local innovation and healthcare champions. Such projects should respond to patient, staff and clinician feedback. Hospitals should set up responsive and agile approaches to governance – supporting appropriate procedures and risk management without stifling good ideas.
Think through the consequences of the patient experience
Healthcare organisations need to balance the need for making efficiency savings with the drive to attract new patients, without losing their focus on patient care. The ultimate objective of PRM is to improve the patient experience within the framework of the care pathway. This can be characterised by three guiding principles :
• An organisation has to be patient relationship centred. This approach applies equally to the ways of working of staff in direct contact with patients and to back-office staff and the entire management team.
• The ‘emotional’ patient experience is as important as the ‘physical’ patient experience. The way in which you do things is equally as important as what you do. Healthcare organisations have to take into account the way patients perceive hospital procedures and actions.
• Patient experiences spread beyond the hospital walls. Today’s patients are ‘connected’, sharing their experiences online and willing to benefit from experiences of others. Patient opinion is a powerful force, so hospitals have to manage their ‘e-reputation’.
From our research, we know that healthcare organisations have few indicators they can use for steering PRM. To ensure that a balance is stuck while improvements are being made, it is imperative therefore to set clear, patient relationship-orientated indicators that can be used to monitor the success of PRM initiatives. For example, hospital queuing times offer a key indicator as they reflect several dimensions of good PRM practice.
PRM doesn’t just happen – the change process must be managed
Only 14% of the healthcare organisations we surveyed actually have a defined patient relationship management role in the organisation (see figure 8). Patient management activities are often spread across many positions as there is no horizontal view of customer relations.
To counter this, we recommend appointing a patient relationship director to be responsible for defining and steering the PRM strategy. This role has to be the advocate of the patient at a senior level – seeing the organisation’s services from the perspective of the patient and their carers.
The ultimate objective of PRM is to improve the patient experience within the framework of the care pathway
In terms of the process itself, it is important to focus on incremental delivery, to draw up a benefits-orientated plan – for example, using hard and soft benefits across a balanced scorecard – to raise awareness and gain the buy-in of staff and patients alike. Equally, while the framework has to be defined at the management level, we advise co-building PRM with patient and staff involvement at every stage. Both innovation and operational efficiency come from the front line.
Innovation is not just about exciting kit and fantastic bits of medical technology, it’s about the way you deliver care
A final question is around how to really manage the complex components across a care pathway effectively. We can look to new and evolving experiences from the NHS in the UK around ‘whole care pathways’ – these propose having a ‘lead provider’ responsible for managing the pathway, but with different subcontractors providing different parts of the care. It is essential that processes and data are ‘joined-up’ across providers, driving a PRM approach.
A PRM Maturity Model
The most valuable lesson we have learned from our research is that PRM is a journey, starting from improvements in discrete patient services, through more joined-up customer care, to maximising the overall ‘customer experience’ of the patient in measurable ways (see figure 9).
Starting on the journey to PRM can appear to be a challenge, but there are proven ways to kick-start the changes. Many patient services changes can be straightforward for hospitals to implement in a short time, to deliver early benefit for hospitals and patients alike. Building on these gains, hospitals can implement broader patient-care initiatives over the longer-term – say 2–-3 years – using the experience to manage return on financial and emotional investments.
Hospitals that are serious about improving the patient experience in the long term should move PRM best practice to the core of there strategies. We know from our project work, a good approach is hiring someone whose role it is to ensure that PRM improves measurable outcomes.
• Online appointment requests;
• Navigation to hospital departments;
• Simpler patient registration for priority groups (e.g. elderly care);
• Online feedback for monitoring and improvement suggestions.
• Online access to patient records;
• Scheduling appointments, including automated reminders;
• Mobile apps for staff and patients;
• Integration with telehealth to enable home treatment.
• Patient dashboards to guide patients through the pathway; (note 10)
• Online diagnosis and triage tools; (note 11)
• Gamification strategies to encourage healthy behaviour (note 12).
Healthcare is evolving in response to patients’ changing needs, towards overall patient health and preventative care
Clearly, as solutions become more involved then so do their costs. For example, while we believe that telehealth brings unequivocal benefits in terms of quality of care, current pilots show that finding the right cost model is not trivial (note 13). While the cost of any solution is important, equally it needs to be measured against less tangible benefits than simple efficiency savings. This goes to the heart of how healthcare is evolving in response to patients’ changing needs. Many hospitals see the goal as moving from a costfocused, break/fix approach to a model that not only looks to improve specific treatment outcomes but also tackles broader questions relating to the overall health of the patient and preventive care. As a result, people maintain a better state of health and therefore become less of a burden to the healthcare system.
An illustration of PRM success is in the UK at Southampton NHS Treatment Centre (note 14),which has integrated PRM best practices into how it designs services around its patients through the following initiatives:
• Aims to carry out all necessary medical tests in one day, to minimise trips back and forth. For first appointments this is achieved 60% of the time.
• Engages staff to make improvements, with a commitment to piloting new ideas quickly. Successful ideas are shared across the organisation.
• Displays patient feedback and satisfaction scores in every department.
• Ensures there is a patient information guide available beside every bed, including a summary of key questions and answers. Examples such as these are by no means isolated. The table on the right illustrates a number of examples drawn from across Europe, showing how organisations are delivering on the potential of PRM.
The nature of healthcare globally is such that all improvement subjects it to the law of diminishing returns. As people live longer their healthcare needs extend but, at the same time, expectations are increasing, putting additional pressure on national finances.
In response, PRM practices are becoming essential to today’s healthcare environments. PRM can help improve effectiveness and efficiency of the healthcare process, while actively engaging with patients across their care pathways. While many hospitals recognise its benefits, progress is hindered by a combination of factors from legacy technology to resistance to change.
Our 2012 research with European hospitals and clinics shows us that PRM practices are supportable by all healthcare organisations. There is no need for large-scale change – indeed, considering PRM as ‘a huge project that will show no benefit for years’ is the wrong starting point. Rather, hospitals should be looking at incremental approaches that can quickly demonstrate tangible benefits to specific target groups – for example outpatients or chronic disease sufferers.
PRM can help improve effectiveness and efficiency of the healthcare process, while actively engaging with patients across their care pathways
However one of our key findings is that it is essential to have a top-level strategy and change programme in order to deliver on the promise of PRM. This requires having clear answers to some direct questions:
• Who is in charge of the PRM vision?
• What are the PRM objectives of the hospital, in what time frame?
• How are patients involved in building the PRM strategy?
• What are the key indicators to measure, and how does the hospital stand currently?
• How will success be measured, in terms that the patient understands (e.g. waiting times)?
While delivering on the promise of PRM, hospital managers need to keep an eye on the bigger picture. Healthcare systems will continue to move away from traditional, functional delivery models towards the end-to-end treatment of patients, wherever they are situated – in hospitals, at home, and everywhere in between. As a result it is becoming increasingly important to adopt a ‘single view of the patient’ – not doing so adds unnecessary costs to an already unaffordable model.
By appropriate targeting of technology and a focus on improving the nature of patient interactions, the most important stakeholder – the patient – stands to gain a great deal. Not only this, but organisations that do not adopt best practice may find themselves at a disadvantage in what is an increasingly diverse and competitive market for healthcare services.
Patient care pathways are becoming increasingly complex across multiple providers to support demands of ageing population, lifestyle changes and new medical developments:
• PRM provides an opportunity to improve the care experience and outcomes for patient and help providers manage those pathways.
• Early, fast changes and benefits can be achieved by listening to the voice of the patient.
• The simplest measures can drive profound change – for example, reducing the time spent by patients in hospital waiting rooms.
• Incremental approaches that deliver benefits along the way are more effective than ‘big-bang’ projects.
About the researchThis survey was conducted by BearingPoint and ESSEC in 2012, the following respondents answered an online questionnaire: public healthcare organisations, including 10 teaching hospitals, 30 hospitals of over 300 beds, and 3 hospitals of under 300 beds; private care organisations including 7 private hospitals and 9 clinics.
Notes and Bibliography
1. ‘Clinical pathways: effects on professional practice, patient outcomes, length of stay and hospital costs (Review)’, The Cochrane Library, Issue 7, The Cochrane Collaboration, Oxford, PDF file, T Rotter et al, 17/03/10, http://bit. ly/170yORZ. The Cochrane Collaboration is published by John Wiley & Sons Ltd.
2. ‘Can cross-channel offer Europe’s retailers a more certain future?’, BearingPoint Institute Report, Issue 003, 09/13, http://inst.be/003XCR
3. E-Health: Patient Relationship Management, University of Fribourg, Switzerland, PDF file: E-government seminar, Dr Andreas Meier et al., 09/07, http://bit.ly/165smfr
4. The service encounter: managing employee/customer interaction in service businesses, Lexington Books, Lanham, MD, USA, John A. Czepiel et al, 07/85, http://amzn. to/17EncX4
5. ‘Services and solutions | For commissioners | What we offer’, NHS Direct, UK, web, date accessed 25/07/13, http://bit. ly/13eemMk
6. Developing NHS Direct: Strategy document for the next three years, webarchive.nationalarchives.gov.uk, Department of Health, London, UK, PDF file, Directorate of Accedss of Choice, 15/04/03, http://bit.ly/18DFoES
7. ‘Well-being | Health kiosk |Health kiosk – a new approach to health services’, sitra.fi/en, Sitra, Helsinki, Finland, web, Antti Kivelä and Marji Illi, date accessed 25/07/13, http://bit. ly/14JoLoF
8. ‘Use of telephone and SMS reminders to improve attendance at hospital appointments: a systematic review’, Journal of Telemedicine and Telecare, Volume 17 (Issue 7): pp 358–364, Sage Publications, London, Per E Hasvold and Richard Wootton, October 2011 http://bit.ly/19ko6vS. This research was publicised by the UK government in a press release: ‘Government | News | Hospitals and patients urged to take action on missed appointments’, gov.uk, Department of Health, London, web: press release, The Rt Hon. Simon Burns MP, 27/08/12, http://bit.ly/167aBfO
9. ‘Innovation, not stagnation: healthcare fit for the 21st Century’, Science Omega Review, UK Issue 2, Laura Ferguson, 19/6/13, http://bit.ly/1catKBO
10. ‘Dashboard data’, GP Business, Issue 8, Campden Publishing, London, UK, Liz Hedgecock and Jim Lewis, Summer 2012, http://bit.ly/145OY1D
11. ‘Symptom checker’, NHS Choices, England, web, date accessed 25/08/13, http://bit.ly/dXqBXG
12. ‘Watch out for gamification’, healthcare-informatics.com, Vendome Group, New York, USA, web: blog, Gabriel Perna, 14/01/13, http://bit.ly/13wFatR
13. ‘Research | Cost effectiveness of telehealth for patients with long term conditions (Whole Systems Demonstrator telehealth questionnaire study): nested economic evaluation in a pragmatic, cluster randomised controlled trial‘, BMJ, London, UK, Catherine Henderson et al., 22/03/13, http://bit. ly/Xud9Oh
14. Feeling better – improving patient experience in hospital, NHS Confederation, London, UK, PDF file: report, 06/01/11, http://bit.ly/hqOv4G
15. Better Health: A Shared Challenge for Hospitals and Primary Health Care, HOPE (European Hospital and Healthcare Federation), Brussels, Belgium, PDF file, HOPE Agora 2011 report, 10/11, http://bit.ly/wM4gDH. Report mentions the Basque Multi-channel Health Service Centre (MHSC) on page 25
17. ‘‘Services & Solutions | For commissioners | Online services invaluable during busy holiday period’, NHS News Direct, England, web: news, date accessed: 25/07/13, http://bit. ly/14jLKAQ
18. ‘QR codes: d’étranges pictos pour faciliter l’accès à l’information’, Reseau–CHU, Limoges, France, web, news, 03/10/11, http://bit.ly/q01tyH. Contact for further information: Phillippe Frugier
19. ‘‘Medical Opinion/Appointment | Make an Appointment’, Healthcare Belgium, Belgium, web, date accessed: 26/07/13, http://bit.ly/1cVTbG4
20. ‘‘Ospedale in un click | Servizi innovativi e multimediali per il Bambino Gesù: benvenuti nell’Ospedale del III Millennio, L’Ospedale Bambino Gesù, Rome, Italy, web, date accessed: 26/07/13, http://bit.ly/13Z5k6f
21. ‘Welcome to Choose and Book’, Choose and Book, NHS, England, web, date accessed 26/07/13, http://bit.ly/MH7K6
22. ‘Home page | Laadukasta hammashoitoa edullisin hinnoin (High-quality dental care at affordable prices)’, Megaklinikka, Helsinki, Finland, web, date accessed: 11/08/13, www. megaklinikka.fi. Megaklinikka is a private dental-care clinic that streamlines operations and applies dynamic pricing to offer low-cost dental care services.
23. ‘On pourra bientôt régler en ligne sa note d’hôpital’, Le Parisien, Paris, France, Daniel Rosenweg , 09/07/13, http://bit. ly/14F5buX